Pig kidney transplantation: an up-to-date guideline

Background: Swine and human beings have many aspects in common that make swine a well-characterized large animal model for kidney transplantation (KTx). However, pigs have some peculiar anatomical characteristics that standardized techniques must adapt to. The aim of this study was to prepare an up-to-date guideline for porcine KTx. Methods: To achieve this goal, we performed a Medline search using the terminology ”kidney’ or ”renal’ and ”transplantation’ and ”pig’ or ”swine’ or ”porcine’. We found over 1,300 published articles since 1963. Only 13 studies focused on the surgical aspect. Furthermore, we reviewed related books and articles about swine anatomical characteristics and surgery. Finally, our experimental experiences of KTx during the last few decades were added to this collection. Results: Proper hosting, fasting, anesthesia, medical therapy and monitoring can prevent postoperative complications. Explantation with a Carrel patch of the aorta facilitates the implantation and prevents future stenosis. Native nephrectomy makes the follow-up of the implanted organ more precise. KTx in the infrarenal fossa via end-to-side anastomosis to the aorta and inferior vena cava followed by ureteroureterostomy are the recommended options for KTx in pigs compared to other possible methods. Conclusion: Pigs, with respect to their characterizations, constitute one of the best large animal models for KTx. Preoperative preparations are as important as the intra- and postoperative management. Using the most adaptable methods of surgery with respect to the specific anatomical characteristics of pigs can prevent undermining the studies and avoid preventable complications and pitfalls. Copyright (c) 2012 S. Karger AG, Base

PROUD: Effects of preoperative long-term immunonutrition in patients listed for liver transplantation

<p>Abstract</p> <p>Background</p> <p>Patients with end stage liver disease are characteristically malnourished which is associated with poor outcome. Formulas enriched with arginine, ω-3 fatty acids, and nucleotides, "immunonutrients", potentially improve their nutritional status. This study is designed to evaluate the clinical outcome of long-term "immunonutrition" of patients with end-stage liver disease while on the waiting list for liver transplantation.</p> <p>Methods/design</p> <p>A randomized controlled double blind multi-center clinical trial with two parallel groups comprising a total of 142 newly registered patients for primary liver transplantation has been designed to assess the safety and efficacy of the long-term administration of ORAL IMPACT^®, an "immunonutrient" formula, while waiting for a graft. Patients will be enrolled the day of registration on the waiting list for liver transplantation. Study ends on the day of transplantation. Primary endpoints include improved patients' nutritional and physiological status, as measured by mid-arm muscle area, triceps skin fold thickness, grip strength, and fatigue score, as well as patients' health related quality of life. Furthermore, patients will be followed for 12 postoperative weeks to evaluate anabolic recovery after transplantation as shown by reduced post-transplant mechanical ventilation, hospital stay, wound healing, infectious morbidities (pneumonia, intraabdominal abscess, sepsis, line sepsis, wound infection, and urinary tract infection), acute and chronic rejection, and mortality.</p> <p>Discussion</p> <p>Formulas enriched with arginine, ω-3 fatty acids, and nucleotides have been proven to be beneficial in reducing postoperative infectious complications and length of hospital stay among the patients undergoing elective gastrointestinal surgery. Possible mechanisms include downregulation of the inflammatory responses to surgery and immune modulation rather than a sole nutritional effect.</p> <p>Trial registration</p> <p>ClinicalTrials.gov NCT00495859</p

PORTAL: Pilot study on the safety and tolerance of preoperative melatonin application in patients undergoing major liver resection: a double-blind randomized placebo-controlled trial

<p>Abstract</p> <p>Background</p> <p>Major surgical procedures facilitate systemic endotoxinemia and formation of free radicals with subsequent inflammatory changes that can influence the postoperative course. Experimental data suggest that preoperative supraphysiological doses of melatonin, a potent immuno-modulator and antioxidant, would decrease postoperative infectious and non-infectious complications induced by major abdominal surgery.</p> <p>Methods/Design</p> <p>A randomized controlled double blind single center clinical trial with two study arms comprising a total of 40 patients has been designed to assess the effects of a single preoperative dose of melatonin before major liver resection. Primary endpoints include the determination of safety and tolerance of the regimen as well as clinical parameters reflecting pathophysiological functions of the liver. Furthermore, data on clinical outcome (infectious and non-infectious complications) will be collected as secondary endpoints to allow a power calculation for a randomized clinical trial aiming at clinical efficacy.</p> <p>Discussion</p> <p>Based on experimental data, this ongoing clinical trial represents an advanced element of the research chain from bench to bedside in order to reach the highest level of evidence-based clinical facts to determine if melatonin can improve the general outcome after liver resection.</p> <p>Trial Registration</p> <p>EudraCT200600530815</p

PROUD: Effects of preoperative long-term immunonutrition in patients listed for liver transplantation-0

<p><b>Copyright information:</b></p><p>Taken from "PROUD: Effects of preoperative long-term immunonutrition in patients listed for liver transplantation"</p><p>http://www.trialsjournal.com/content/8/1/20</p><p>Trials 2007;8():20-20.</p><p>Published online 27 Aug 2007</p><p>PMCID:PMC2018725.</p><p></p>n after giving informed consent. Study nutrition ends on the day of transplantation. Subjects are randomized to two parallel groups treated for study or control product. Furthermore, patients will be followed for 12 weeks after transplantation

Efficacy of Technical Modifications to the Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) Procedure

Objectives:. To compare the outcomes of modified-Associating Liver Partition and Portal vein Ligation for Staged hepatectomy (ALPPS) techniques with those of conventional-ALPPS. Background:. ALPPS is an established technique for treating advanced liver tumors. Methods:. PubMed, Web of Science, and Cochrane databases were searched. The outcomes were assessed by single-arm and 2-arm analyses. Results:. Seventeen studies containing 335 modified-ALPPS patients were included in single-arm meta-analysis. The estimated blood loss was 267 ± 29 mL (95% confidence interval [CI], 210–324 mL) during the first and 662 ± 51 mL (95% CI, 562–762 mL) during the second stage. The operation time was 166 ± 18 minutes (95% CI, 131–202 minutes) during the first and 225 ± 19 minutes (95% CI, 188–263 minutes) during the second stage. The major morbidity rate was 14% (95% CI, 9%–22%) after the first stage. The future liver remnant hypertrophy rate was 65.2% ± 5% (95% CI, 55%–75%) and the interstage interval was 16 ± 1 days (95% CI, 14–17 days). The dropout rate was 9% (95% CI, 5%–15%). The overall complication rate was 46% (95% CI, 37%–56%) and the major complication rate was 20% (95% CI, 14%–26%). The postoperative mortality rate was 7% (95% CI, 4%–11%). Seven studies containing 215 patients were included in comparative analysis. The hypertrophy rate was not different between 2 methods (mean difference [MD], –5.01; 95% CI, –19.16 to 9.14; P = 0.49). The interstage interval was shorter for partial-ALPPS (MD, 9.43; 95% CI, 3.29–15.58; P = 0.003). The overall complication rate (odds ratio [OR], 10.10; 95% CI, 2.11–48.35; P = 0.004) and mortality rate (OR, 3.74; 95% CI, 1.36–10.26; P = 0.01) were higher in the conventional-ALPPS. Conclusions:. The hypertrophy rate in partial-ALPPS was similar to conventional-ALPPS. This shows that minimizing the first stage of the operation does not affect hypertrophy. Moreover, the postoperative overall morbidity and mortality rates were lower following partial-ALPPS

Heterogeneous indications and the need for viability assessment: An international survey on the use of machine perfusion in liver transplantation

Although machine perfusion (MP) is being increasingly adopted in liver transplantation, indications, timing, and modality are debated. To investigate current indications for MP a web-based Google Forms survey was launched in January 2021 and addressed to 127 experts in the field, identified among first and corresponding Authors of MP literature in the last 10&nbsp;years. The survey presented 10 real-life cases of donor-recipient matching, asking whether the liver would be accepted (Q1), whether MP would be used in that particular setting (Q2) and, if so, by which MP modality (Q3) and at what timing during preservation (Q4). Respondents could also comment on each case. The agreement was evaluated using Krippendorff's alpha coefficient. Answers from 39 (30.1%) participants disclosed significant heterogeneity in graft acceptance, MP indications, technique, and timing. Agreement between respondents was generally poor (Q1, α&nbsp;=&nbsp;0.11; Q2, α&nbsp;=&nbsp;0.14; Q3, α&nbsp;=&nbsp;0.12, Q4, α&nbsp;=&nbsp;0.11). Overall, respondents preferred hypothermic MP and an end-ischemic approach in 56.3% and 81.1% of cases, respectively. A total of 18 (46.2%) participants considered only one MP approach, whereas 17 (43.6%) and 3 (7.7%) considered using alternatively 2 or 3 different techniques. Of 38 comments, 17 (44.7%) were about the use of MP for graft viability assessment before implantation. This survey shows considerable variability in MP indications, emphasizing the need to identify scenarios of optimal utilization for each technique. Viability assessment emerges as a fundamental need of transplant professionals when considering the use of MP

Surgical outcomes of gallbladder cancer: the OMEGA retrospective, multicentre, international cohort study

Background Gallbladder cancer (GBC) is rare but aggressive. The extent of surgical intervention for different GBC stages is non-uniform, ranging from cholecystectomy alone to extended resections including major hepatectomy, resection of adjacent organs and routine extrahepatic bile duct resection (EBDR). Robust evidence here is lacking, however, and survival benefit poorly defined. This study assesses factors associated with recurrence-free survival (RFS), overall survival (OS) and morbidity and mortality following GBC surgery in high income countries (HIC) and low and middle income countries (LMIC).Methods The multicentre, retrospective Operative Management of Gallbladder Cancer (OMEGA) cohort study included all patients who underwent GBC resection across 133 centres between 1st January 2010 and 31st December 2020. Regression analyses assessed factors associated with OS, RFS and morbidity.Findings On multivariable analysis of all 3676 patients, wedge resection and segment IVb/V resection failed to improve RFS (HR 1.04 [0.84-1.29], p = 0.711 and HR 1.18 [0.95-1.46], p = 0.13 respectively) or OS (HR 0.96 [0.79-1.17], p = 0.67 and HR 1.48 [1.16-1.88], p = 0.49 respectively), while major hepatectomy was associated with worse RFS (HR 1.33 [1.02-1.74], p = 0.037) and OS (HR 1.26 [1.03-1.53], p = 0.022). Furthermore, EBDR (OR 2.86 [2.3-3.52], p &lt; 0.0010), resection of additional organs (OR 2.22 [1.62-3.02], p &lt; 0.0010) and major hepatectomy (OR 3.81 [2.55-5.73], p &lt; 0.0010) were all associated with increased morbidity and mortality. Compared to LMIC, patients in HIC were associated with poorer RFS (HR 1.18 [1.02-1.37], p = 0.031) but not OS (HR 1.05 [0.91-1.22], p = 0.48). Adjuvant and neoadjuvant treatments were infrequently used.Interpretation In this large, multicentre analysis of GBC surgical outcomes, liver resection was not conclusively associated with improved survival, and extended resections were associated with greater morbidity and mortality without oncological benefit. Aggressive upfront resections do not benefit higher stage GBC, and international col-laborations are needed to develop evidence-based neoadjuvant and adjuvant treatment strategies to minimise surgical morbidity and prioritise prognostic benefit.Funding Cambridge Hepatopancreatobiliary Department Research Fund.Copyright &amp; COPY; 2023 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)